This docum ent does not reflect the intent or official position of the bill sponsor or House of Representatives.
STORAGE NAME: h1067.HRS
DATE: 3/21/2023
HOUSE OF REPRESENTATIVES STAFF ANALYSIS
BILL #: HB 1067 Autonomous Practice by an Advanced Practice Registered Nurse
SPONSOR(S): Giallombardo
TIED BILLS: IDEN./SIM. BILLS: SB 1058
REFERENCE ACTION ANALYST STAFF DIRECTOR or
BUDGET/POLICY CHIEF
1) Healthcare Regulation Subcommittee Osborne McElroy
2) Health & Human Services Committee
SUMMARY ANALYSIS
An advanced practice registered nurse (APRN) is a licensed professional nurse who is additionally licensed in
an advanced nursing practice, including certified nurse midwives (CNM), certified nurse practitioners, certified
registered nurse anesthetists, clinical nurse specialists, and psychiatric nurses. Each specialty requires training
and education specific to the specialty area and certification with a national board that has been approved by
the Board of Nursing. There are approximately 54,447 APRNs actively licensed to practice in Florida.
APRNs are generally required to practice under a supervising physician’s protocol and only to the extent that
the written protocol allows. In 2020, the Legislature passed legislation authorizing APRNs meeting certain
criteria to practice “autonomously,” or without physician supervision or a supervisory protocol, in specified
settings. Currently, 8,185 APRNs are registered for autonomous practice.
Under current law, APRNs registered for autonomous practice, including specialty APRNS, may only provide
primary care services without physician supervision. However, certified nurse midwives with a patient transfer
agreement with a hospital and a written referral agreement with a physician may autonomously engage in
midwifery practices.
The Council on Advanced Practice Registered Nurse Autonomous Practice was established in statute in 2020
with the purpose of recommending standards of practice for APRNs who practice autonomously to the Board.
HB 1067 removes the requirement that autonomous APRNs practice exclusively in primary care. The bill
authorizes registered autonomous APRNs to perform their general functions as an APRN, and any specific
functions related to their specialty area without physician supervision.
The bill removes the requirement that CNMs have a written patient transfer agreement with a hospital and a
written referral agreement with a physician in order to engage autonomously in nurse midwifery. Instead, the
bill requires CNMs who provide out-of-hospital birth services to have a written plan for the delivery of
emergency care.
The bill repeals the Council on Advanced Practice Registered Nurse Autonomous Practice effective July 1,
2024.
The bill has an indeterminate, insignificant negative fiscal impact on DOH which can be absorbed within
current resources. The bill has no fiscal impact on local governments.
The bill provides an effective date of July 1, 2023.
STORAGE NAME: h1067.HRS PAGE: 2
DATE: 3/21/2023
FULL ANALYSIS
I. SUBSTANTIVE ANALYSIS
A. EFFECT OF PROPOSED CHANGES:
Background
Advanced Practice Registered Nurses
An advanced practice registered nurse (APRN) is a licensed professional nurse who is additionally
licensed in an advanced nursing practice, including certified nurse midwives, certified nurse
practitioners, certified registered nurse anesthetists, clinical nurse specialists, and psychiatric nurses.
1
There are approximately 54,447 APRNs actively licensed to practice in Florida.
2
APRNs are regulated under part I of ch. 464, F.S., the Nurse Practice Act. The Board of Nursing
(Board), housed within the Department of Health (DOH), is responsible for establishing by rule the
eligibility criteria for applicants to be licensed as APRNs and the applicable regulatory standards for
APRN nursing practices.
3
The Board is also responsible for administratively disciplining an APRN who
commits an act prohibited by under ss. 464.018 or 456.072, F.S.
4
To be eligible to be licensed as an
APRN, an applicant must be licensed as a registered nurse, have a master’s degree in a nursing
clinical specialty area with preparation in specialized practitioner skills, and submit proof that the
applicant holds a current national advanced practice certification from a Board-approved nursing
specialty board.
5
In addition to the practice of professional nursing,
6
APRNs perform advanced-level nursing acts
approved by the Board as appropriate for APRNs to perform by virtue of their post-basic specialized
education, training, and experience. Advanced or specialized nursing acts may only be performed if
authorized under a supervising physician’s protocol.
7
In addition to advanced or specialized nursing
practices, APRNs are authorized to practice certain medical acts, as opposed to nursing acts, as
authorized within the framework of an established supervisory physician’s protocol.
8
APRNs are required to practice under a supervising physician’s protocol and only to the extent that the
written protocol allows.
9
APRN Specialties
An APRN may be certified in one of five specialty roles: a certified nurse practitioner (CNP), certified
nurse midwife (CNM), clinical nurse specialist (CNS), certified registered nurse anesthetist (CRNA), or
psychiatric nurse.
10
In order to practice as an APRN in any of these specialties, an individual must have
a masters’ degree or post-master’s certificate in the respective nursing clinical specialty area and
national advanced practice certification from an approved nursing specialty board,
11
in addition to being
licensed as a professional nurse.
12
1
S. 464.003(3), F.S. In 2018, the Florida Legislature enacted a law which changed the occupational title from “Advanced Registered
Nurse Practitioner (APRN)” to “Advanced Practice Registered Nurse (APRN),” and also reclassified a Clinical Nurse Specialist as a
type of APRN instead of a stand-alone occupation (see ch. 2018-106, Laws of Fla.).
2
Department of Health. Agency Analysis for HB 1067 (2023), p. 5.
3
S. 464.004, F.S.
4
S. 464.018, F.S.
5
S. 464.012(1), F.S., and Rule 64B9-4.002, F.A.C.
6
“Practice of professional nursing” means the performance of those acts requiring substantial specialized knowledge, judgment, and
nursing skill based upon applied principles of psychological, biological, physical, and social sciences. See s. 464.003(19), F.S.
7
S. 464.012(3)-(4), F.S.
8
S. 464.003, F.S., and s. 464.012, F.S.
9
S. 464.012, F.S.
10
S. 464.012(4), F.S.
11
See Rule 64B9-4.002 Requirements for Licensure for the list of Board approved specialty boards.
12
Florida Board of Nursing, Advanced Practice Registered Nurse (APRN). Available at https://floridasnursing.gov/nursing-
faqs/advanced-practice-registered-nurse-aprn/ (last visited March 17, 2023). STORAGE NAME: h1067.HRS PAGE: 3
DATE: 3/21/2023
Certified Nurse Practitioners (CNP)
CNPs typically receive education and training to work with a specific patient population, such as
women’s health, gerontology, or pediatrics. They employ a whole-health approach with a focus on
focus on health promotion, disease prevention and health education and counseling.
13
Under an established protocol with a supervising physician, a CNP may perform the following acts:
Manage selected medical problems.
Order physical and occupational therapy.
Initiate, monitor, or alter therapies for certain uncomplicated acute illnesses.
Monitor and manage patients with stable chronic diseases.
Establish behavioral problems and diagnosis and make treatment recommendations.
Certified Nurse Midwife (CNM)
CNMs provide care during pregnancy, childbirth, and the postpartum period, as well as sexual and
reproductive health care, gynecologic health care, and family planning services.
14
A CNM may perform the following procedures to the extent authorized by the established protocol
approved by the health care facility in which they are operating, or by the supervising physician if
performing a delivery in a patient’s home:
15
Perform superficial minor surgical procedures.
Manage the patient during labor and delivery to include amniotomy, episiotomy, and repair.
Order, initiate, and perform appropriate anesthetic procedures.
Perform postpartum examination.
Order appropriate medications.
Provide family-planning services and well-woman care.
Manage the medical care of the normal obstetrical patient and the initial care of a newborn
patient.
Clinical Nurse Specialists (CNS)
A CNS is trained to be an expert clinician in a specialized area, such as a certain population, setting, or
disease state.
16
Within the framework of an established protocol with a medical facility, a CNS may
perform the following acts:
Assess the health status of individuals and families using methods appropriate to the population
and area of practice.
Diagnose human responses to actual or potential health problems.
Plan for health promotion, disease prevention, and therapeutic intervention in collaboration with
the patient or client.
Implement therapeutic interventions based on the nurse specialist’s area of expertise and within
the scope of advanced nursing practice, including, but not limited to, direct nursing care,
counseling, teaching, and collaboration with other licensed health care providers.
Coordinate health care as necessary and appropriate and evaluate with the patient or client the
effectiveness of care.
13
American Association of Nurse Practitioners, What’s a Nurse Practitioner (NP)? Available at https://www.aanp.org/about/all-about-
nps/whats-a-nurse-practitioner (last visited March 17, 2023).
14
American College of Nurse-Midwives, Definition of Midwifer and Scope of Practice of Certified Nurse-Midwives and Certified
Midwives. Available at
https://www.midwife.org/acnm/files/cclibraryfiles/filename/000000007476/Definition%20Midwifery%20Scope%20of%20Practice_2021.p
df (last visited March 17, 2023).
15
S. 464.012(4)d), F.S.
16
National Association of Clinical Nurse Specialists, What is a CNS? Available at http://nacns.org/about-us/what-is-a-cns/ (last visited
March 17, 2023). STORAGE NAME: h1067.HRS PAGE: 4
DATE: 3/21/2023
Certified Registered Nurse Anesthetist (CRNA)
CRNAs provide pain medication, specifically anesthesia, to patients before, during, and after surgery. A
CRNA may, within the limitations set by the established protocol of the facility in which the anesthetic
service is performed, conduct a pre-anesthesia evaluation, order and administer the anesthetic as
determined appropriate, monitor and interpret the patient’s vital signs, manage the patient during
surgery and in recovery.
17
Under current law, a CRNA is only authorized to administer anesthesia under the onsite medical
direction of a licensed physician
18
or dentist.
19
Psychiatric Nurse
Psychiatric nurses are trained with a clinical focus on individuals, families, or populations across the
lifespan at risk for developing mental problems or having a psychiatric diagnosis. They receive training
in psychiatric assessment and diagnosis, advanced clinical management of psychiatric disorders,
including the prescription and management of psychotropic medications, and therapy modalities.
20
Under current law, psychiatric nurses may prescribe psychotropic controlled substances for the
treatment of mental disorders within the framework of an established protocol with a psychiatrist.
21
APRN Autonomous Practice in Florida
APRNs meeting certain criteria are authorized to practice autonomously in specified settings.
22
Prior to
engaging in autonomous practice, an APRN must register with the Board and meet the following
requirements in addition to those required for initial licensure as an APRN:
23
Hold an active and unencumbered Florida license, or multistate license
pursuant to s. 464.0095, F.S.;
24
Have completed at least 3,000 clinical practice hours or clinical instructional
hours
25
supervised by an actively licensed physician within the 5-year period
immediately preceding the registration request;
Not been subject to any disciplinary action during the five years immediately
preceding the application;
Completed three graduate-level semester hours in pharmacology and three
graduate-level semester hours in differential diagnosis within the 5-year
period preceding the registration request; and
Any other appropriate requirement adopted by rule by the Board.
26
The registration must be renewed biennially and the renewal coincides with the licensure renewal
period for the APRN. To maintain registration, an APRN must complete at least 10 hours of continuing
education approved by the Board for each biennial renewal in addition to the 30 hours of continuing
17
S. 464.012(4)(b), F.S.
18
See Chs. 458 and 459, F.S.
19
S. 395.0191, F.S. See also, Ch. 466, F.S.
20
University of Florida, College of Nursing, Psychiatric-Mental Health Nurse Practitioners. Available at
https://nursing.ufl.edu/programs/doctor-of-nursing-practice-dnp/bsn-to-dnp/psychiatric-mental-health-nurse-
practitioner/#:~:text=The%20psychiatric%2Dmental%20health%20nurse,or%20having%20a%20psychiatric%20diagnosis. (last visited
March 18, 2023).
21
S. 464.012(4)(e), F.S.
22
S. 464.0123, F.S.
23
Id.
24
Florida is a member of the Nurse Licensure Compact. See s. 464.0095, F.S.
25
“Clinical instruction” as education provided by faculty in a clinical setting in a graduate program leading to a master’s or doctoral
degree in a clinical nursing specialty area. See 464.0123(1)(c), F.S.
26
The Board has imposed specific course content requirements for the pharmacology and differential diagnosis courses required in
statute, but has not imposed any additional requirements by rule. See Rule 64B9-4.020. STORAGE NAME: h1067.HRS PAGE: 5
DATE: 3/21/2023
education required for renewal of the APRN license.
27
There are currently 8,185 APRNs registered for
autonomous practice in Florida.
28
Scope of Practice
An autonomous APRN is authorized to engage in primary care practice, which includes family
medicine, general pediatrics, and general internal medicine, without physician supervision.
29
Autonomous APRNs may perform the general functions of an APRN as provided in statute
30
without
physician supervision, but exclusively in the context of primary care, regardless of their specialty
training.
31
Additionally, autonomous APRNs are authorized to perform the following acts without physician
supervision:
32
Admit, discharge, or manage the care of a patient requiring the services of a
health care facility, as authorized under federal law or rule.
Provide a signature, certification, stamp, verification, affidavit, or other
endorsement that is otherwise required by law to be provided by a physician.
Certify causes of death and sign, correct, and file death certificates.
Execute a certificate to subject a person to involuntary examination under the
Baker Act.
Perform certain physical examinations currently reserved to physicians and
physician assistants by Florida law, such as examinations of pilots, law
enforcement officers, and suspected child abuse victims.
Examine and report on a ward’s medical and mental health conditions in the
annual guardianship plan submitted to the court.
An autonomous APRN may not perform any surgical procedures except subcutaneous surgical
procedures.
33
A CNM who is registered to practice autonomously may perform midwifery services
34
if they have a
written patient transfer agreement with a hospital and a written referral agreement with a Florida-
licensed physician.
35
Council on Advanced Practice Registered Nurse Autonomous Practice
The Council on Advanced Practice Registered Nurse Autonomous Practice (Council) was established
in statute in 2020 with the purpose of making recommendations to the Board regarding the standards of
practice for APRNs who practice autonomously.
36
The Board may choose to adopt a recommendation,
reject a recommendation, or otherwise act on it as the Board deems appropriate. If the Board rejects a
recommendation, it must state with particularity its reason for such rejection. The Board must provide
the Council an opportunity to modify its recommendation, and the Board must also consider the
modified recommendation. The 9-member Council is required to include:
37
27
S. 464.0123(5), F.S.
28
Supra, note 2.
29
S. 464.0123(3), F.S.
30
The general functions of an APRN include: prescribing, dispensing, administering, and ordering of any drug with some limitations on
the prescription of controlled substances, initiating appropriate therapies for certain conditions, ordering diagnostic tests and physical
and occupational therapy. See s. 464.012(3), F.S.
31
Supra, note 29
32
Supra, note 29.
33
Id.
34
See s. 464.012(4)(c), F.S.
35
S. 464.0123(3)(b), F.S.
36
S. 464.0123(4), F.S.
37
Id. STORAGE NAME: h1067.HRS PAGE: 6
DATE: 3/21/2023
Four APRNs appointed by the Board of Nursing who have experience practicing advanced or
specialized nursing;
Two physicians appointed by the Board of Medicine who are physicians and members of the
Board of Medicine;
Two physicians appointed by the Board of Osteopathic Medicine who are physicians and
members of the Board of Osteopathic Medicine; and
The State Surgeon General or his or her designee, who serves as chair of the Council.
Council members are appointed for 4-year terms, and may not serve more than two consecutive
terms.
38
Effect of the Bill
HB 1067 removes the requirement that autonomous APRNs practice exclusively in primary care. The
bill authorizes registered autonomous APRNs to perform their general functions as an APRN, and any
specific functions related to their specialty area without physician supervision.
The bill removes the requirement that CNM have a written patient transfer agreement with a hospital
and a written referral agreement with a physician in order to engage autonomously in nurse midwifery.
Instead, the bill requires certified nurse midwives who provide out-of-hospital birth services to have a
written plan for the delivery of emergency care. A copy of the plan must be maintained on file and
include:
The name and address of the closest hospital;
Reasons why an emergency transfer might be required; and
Emergency medical services which are to be used in the event of an emergency.
The bill repeals the Council on Advanced Practice Registered Nurse Autonomous Practice effective of
July 1, 2024.
The bill provides an effective date of July 1, 2023.
B. SECTION DIRECTORY:
Section 1: Amends s. 395.0191, F.S., relating to staff membership and clinical privileges.
Section 2: Amends s. 464.0123, F.S., relating to autonomous practice by advanced practice
registered nurse.
Section 3: Provides an effective date of July 1, 2023.
II. FISCAL ANALYSIS & ECONOMIC IMPACT STATEMENT
A. FISCAL IMPACT ON STATE GOVERNMENT:
1. Revenues:
None.
2. Expenditures:
The bill has an indeterminate, insignificant negative impact on DOH which is expected to be
absorbed within current resources.
B. FISCAL IMPACT ON LOCAL GOVER NMENTS:
38
Id. STORAGE NAME: h1067.HRS PAGE: 7
DATE: 3/21/2023
1. Revenues:
None.
2. Expenditures:
None.
C. DIRECT ECONOMIC IMPACT ON PRIVATE SECTOR:
None.
D. FISCAL COMMENTS:
None.
III. COMMENTS
A. CONSTITUTIONAL ISSUES:
1. Applicability of Municipality/County Mandates Provision:
Not applicable. The bill does not appear to affect county or municipal governments.
2. Other:
None.
B. RULE-MAKING AUTHORITY:
The Board has sufficient rulemaking authority to implement this bill’s provisions.
C. DRAFTING ISSUES OR OTHER COMMENTS:
None.
IV. AMENDMENTS/COMMITTEE SUBSTITUTE CHANGES